High Yield ENT COPY Flashcards

1
Q

A 22-year-old presents to the GP with difficulty breathing through his nose following a fistfight. During the fight, he sustained a blow to the face and fell to the ground, but denies losing consciousness. He has not experienced any vomiting or any other symptoms, except for difficulty breathing through his right nostril. On examination, there is a bruise around the right cheekbone and a red swelling arising from the right nasal septum.

What is the next most appropriate management?

Routine referral to ENT
Urgent referral to ENT
Follow-up in 1 week
CT head
Conservative measures i.e. cold compress

A

Urgent referral to ENT - nasal septal haematoma → needs urgent evacuation under GA w/ packing +/- suturing

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2
Q

causes of epistaxis

A

Causes include trauma, insertion of foreign bodies, bleeding disorders, angiofibroma, cocaine
Presentation = nose bleeding (usually unilateral), can also be vomiting

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3
Q

blood supply to the nose

A

Anterior
Most common
Nasal septum
Littles area (kiesselbachs plexus)
Posterior
Nasopharynx
Woodruff plexus

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4
Q

summary of management of epistaxis

A

Management
1. Position change and pinch for 20 mins
1. If bleed visible – silver nitrate cautery, if not – anterior nasal packing
1. If haemodynamically unstable or bleed not visualized admit to hospital
1. Sphenopalatine ligation in theatre

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5
Q

why can cocaine cause nose bleeds

A

cocaine is a powerful vasoconstrictor and repeated use may result in obliteration of the septum.

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6
Q

why do we always need to exclude septal haematoma

A

Septal necrosis + nasal collapse if untreated

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7
Q

presentation of septal haematoma

A
  • Nasal obstruction, pain, rhinorrhea
  • Boggy swelling, soft & fluctuant palpation, asymmetry of septum w/ swelling
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8
Q

complications of septal ahematoma

A

septal abscess, septal necrosis + nasal collapse (saddle nose)

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9
Q

manaegemnt of septal haematoma

A

Mx by aspiration or drainage, suture, packing, Abx

  1. No need for XR if simple nasal # - cartilaginous injury won’t show & radiographs won’t alter Mx
  2. Ideally seen by ENT 5-10d post-injury
  3. Re-assess for deviation after 7d once swelling subsided – septoplasty 12m post-injury
  4. Only intervene if cosmetic deformity or nasal obstruction
  5. Needs reduction within 14d
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10
Q

A 6-year-old boy presents to the GP with his parents. He had a tonsillectomy 6 days ago and is recovering well, but they are worried after finding spots of blood on his pillowcase this morning. He has no other significant medical history. On examination, the boy appears well with no active bleeding, and observations are within normal limits.

What is the next most appropriate management?

Reassurance & discharge
Conservative measures i.e. cold compress
Routine referral to ENT
Urgent referral to ENT
Prescribe tranexamic acid

A

Urgent referral to ENT – always have low suspicion for post-op tonsillectomy hemorrhage esp. in kids!

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11
Q

FeverPAIN criteria or Centro

A

Offer antibiotics:
feverpain score 2 or 3
Centor 3 or 4

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12
Q

FeverPAIN

A

More accurate than Centor
- Fever
- Pus
- Attending early (within 3 days)
- Inflamed tonsils
- No cough

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13
Q

Centor criteria

A

Fever over 38ºC
Tonsillar exudates
Absence of cough
Tender anterior cervical lymph nodes (lymphadenopathy)

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14
Q

Indications for ABx:

A
  • Marked systemic upset
  • RF Hx
  • Increased risk from acute infection
  • Centor/FEVER Pain score
  • Unilateral peritonsillitis
  • Give pen v or clarithro for 7-10d
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15
Q

Red flags/complications of tonsilitis

A
  • Quinsy
  • Tonsillitis
  • Sinusitis
  • Mastoiditis
  • Otitis media
  • Laryngitis
  • Scarlet fever, RF
  • Lemierre’s syndrome
  • Epiglottitis
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16
Q

which antibiotics for tonsilitis

A

Penicillin V (also called phenoxymethylpenicillin) for a 10-day course is typically first-line. It has a relatively narrow spectrum of activity and is effective against Streptococcus pyogenes.

Clarithromycin is the usual first-line choice in true penicillin allergy.

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17
Q

bacterial causes of sore throat

A

The most common cause: group A streptococcus (Streptococcus pyogenes). This can be effectively treated with penicillin V (phenoxymethylpenicillin).

The second most common bacterial cause of tonsillitis is Streptococcus pneumoniae.

Other causes:

Haemophilus influenzae
Moraxella catarrhalis
Staphylococcus aureus

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18
Q

summary of acute sore throat

A
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19
Q

Classic exam question: if give amox/ampicillin & develops macpap rash, think:

A

EBV

a maculopapular, pruritic rash develops in around 99% of patients who take ampicillin/amoxicillin whilst they have infectious mononucleosis

-> avoid contact sport for 6-8 weeks due to splenomegaly

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20
Q

Tonsillectomy Criteria:

A

Recurrent infection*…
* 7 ep. in 1 year
* 5 ep. for 2 years
* 3 ep. for 3 years
* Disabling & prevent normal functioning
Suspected malignancy
PSA/sleep disordered breathing in children
Recurrent quinsy
Severe immune deficiency

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21
Q

types of post-op tonsillectomy bleeds

A

Primary (<24hours)

Inadequate haemostasis

Secondary (>24 hr, usually 4-9d post-op)

Unclear aetiology – infection, fibrin clots, technique

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22
Q

management of post tonsillectomy bleed

A

Mx:
Always admit of Hx of blood
ABC + other measures
Examine throat
NOTIFY ENT REG***, involve paeds/anaesthetics early

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23
Q

A 59-year-old diabetic man sees his GP due to pain in his left ear. It has been there for the past 6 weeks, but in the last 2 weeks, he has been having ‘smelly white stuff’ coming out of his ear. He also complains about a headache around his left temporal area for the last few weeks not relieved by paracetamol.

On examination, he is apyrexial and neurological examination is normal. There is some creamy discharge in his left ear and on otoscopy, the walls are erythematous and sloughy. The tympanic membrane is normal.

Given the likely diagnosis, which of the following antibiotics will provide the best cover for the likely causative agent?

Amoxicillin
Gentamicin
Ciprofloxacin
Flucloxacillin
Metronidazole

A

Ciprofloxacin – OE in old diabetics → cover for Pseudomonas

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24
Q

otitis externa summary

A

History
- otalgia, pruritus, otorrhoea

Causes
- P.aueroginosa, S.aureus, candida, aspergillus
- moisture, trauma, absence of wax, dermatitis, swimming, hearing aids

Management
* Aural toilet (hoover out debris)
* ABx + steroid drops e.g. gentamicin
* KEEP EAR DRY

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25
Q

Necrotising/malignant OE

A

Temportal+ base of skull osteomyelitis - spread via the osseocartilaginous junction
- P.aueroginosa

Be aware the: diabetic, immunocompromised, elderly

Suspicious features
- Deep-seated pain, out of proportion
- Granulations
- Non-resolving OE

Other symptoms
- dysphagia
- hoarsness
- facila nerve dysfunction

Management
- admission
- CT scan
- IV abx e.g. ciprofloxacin

Complications
- Sinus thrombosis
- Meningitis
- Cerebral abscess

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26
Q

A 30yro woman presents to her GP with dizziness, nausea, and unilateral hearing loss which has been consistent for the past 2 days. Upon questioning, she denies having ever experienced symptoms like this before. She reports no tinnitus, otalgia or otorrhoea.

Upon examination, she is afebrile and does not appear to be in pain. Examination of her ears shows no abnormalities.

What is the most likely diagnosis?
Meniere’s disease
Benign Paroxysmal positional vertigo
Otitis media
Acute Labyrinthitis
Vestibular Neuronitis

A

Acute Labyrinthitis – pt has hearing loss + prolonged/constant vertigo

This patient has presented with symptoms of nausea, dizziness, and hearing loss. The likely diagnosis is labyrinthitis due to hearing loss. Labyrinthitis is inflammation of the labyrinth of the inner ear and presents with these symptoms and a sensorineural hearing loss.

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27
Q

acute lab vs vest neuronitis

A

Vestibular neuronitis is an inflammation of the eighth cranial nerve and presents similarly to labyrinthitis, however, it can be distinguished from the condition by the fact that vestibular neuronitis does not cause hearing loss.

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28
Q

conditions which cause vertigo

A

Peripheral causes
* BPPV
* Meniers
* Vestibular neuritis
* Labyrinthitis
* Acoustic neuroma

Central causes
* Cerebellar stroke: ~75% of them present with dizziness/vertigo
* Other: acoustic neuroma, ototoxic drugs, MS (not MND)
* Vestibular Migraine
* vertebrobasilar ischaemia – dizziness on neck extension

29
Q

BPPV:

A

sudden onset, lasts secs, nystagmus, otolith, Dix-Hallpike +ive on affected side

30
Q

Meniere’s:

A

endolymphatic hydrops, vertigo, EPISODIC mins-hours, aural fullness, low frequency HL, Fam Hx, Romberg’s +stepping test +ive, min

31
Q

Vestibular neuritis:

A

inflammation of the vestibular nerve, severe, prolonged vertigo, N+V, viral infection HSV

32
Q

Labyrinthitis:

A

Inflammation of inner ear, severe, prolonged vertigo, N+V, recent URTI

33
Q

Acoustic neuroma

A

benign, neoplasm of vestibular nerve, unilateral, SN Hearing loss +/- facial palsy

34
Q

causes of hearing loss

A

Sensorineural
- Presbycusis
- Labyrinthitis
- Acoustic neruoma
- Sudden sensorineural hearing loss
Conductive
- Otosclerosis
- glue ear

Drugs
- aminoglycoside
- furosemide aspirin

35
Q

Webers: conductive

A

will localise to the affected ear

36
Q

webers: sensorineural

A

will localise to unaffected ear

37
Q

rinnes test: conductive

A

Bone conduction > air conduction

38
Q

rinnes test: sensor

A

AC>BC

39
Q

Presbycusis –

A

age related SN hearing loss, higher frequencies

40
Q

Otosclerosis:

A

Autosomal dominant, replacement of normal bone by vascular spongy bone. Onset is usually at 20-40 years - features include:conductive deafness
tinnitus
tympanic membrane - 10% of patients may have a ‘flamingo tinge’, caused by hyperaemia
positive family history

41
Q

labyrinthitis –

A

LOSS of hearing
+ vertigo, N+V, dizziness

42
Q

A 32-year-old East Asian woman presents to A&E with a severe headache. It started suddenly when she was driving home last night and not relieved by simple painkillers. On examination, her left pupil is red and dilated. She has a past medical history of type 1 DM, asthma, and recently started amitriptyline for her fibromyalgia.

Considering the most likely diagnosis, what is the most appropriate management?

Topical antibiotics
Co-codamol and metoclopramide
High-flow oxygen and sumatriptan
Topical timolol
IV acetazolamide

A

IV acetazolamide – this patient likely has acute-angle closure glaucoma; acetazolamide > timolol due to Hx of asthma

43
Q

why does acute angle closure gluacoma often occur at night

A

night due to iridocorneal angle reduction, reducing aqueous humour drainage

44
Q

which drug class can cause acute closure

A

anticholinergics e.g. amitriptyline have anti-M effects thus pupil dilation also make it worse

45
Q

AACG: A True Ophthalmic Emergency!

A

Symptoms
- Extremely painful red eye
- N&V
- Reduced acuity, blurry vision

Examination
- Cloudy cornea
- Fixed, dilated, irregular pupil
- Raised IOP → rock-hard

Mx: reduce IOP quick!!!
REFER TO OPHTHALMOLOGIST
Acutely…
- Lie flat on back
- Pilocarpine drops
- Topical B-blocker
- Acetazolamide IV

Long-term definitive → bilateral YAG peripheral iridotomy

46
Q

red eye differentials: painful

A

1. Is there fluoresceine uptake
Yes:
- Keratitis
- corneal abrasion

2. No fluoresceine uptake: Is there raised intraocular pressure e.g. >24mmHh
Yes:
- AACG

No raised IOP: Is there consensual photopbia e.g. when light put close to eye
Yes: Anterior uveitis (think SLE)
No: scleritis

47
Q

summary of red eye with no injury

A
48
Q

scleritis vs episcleritis

A

Scleritis
- autoimmune
- Very painful
- DOES NOT BLANCHE WITH PHENYLEPHIRNE
- associated with RA, GPA, SLE
- management: systemic steroids/NSAIDs +- topical ABx

Episcleritis
- idiopathic ifnlammation
- NOT painful
- DOES BLANCH WITH PHENYLEPHRINE
- common
- usually idiopathic or : IBD, RA

49
Q

A 35-year-old woman presents to the GP complaining that her vision is “like looking through a tube”. She occasionally experiences a moderate headache that is not eased by paracetamol. Her visual field assessment report during her routine appointment with the optometrist is shown below.

What other sign or symptom would you specifically ask about?

Limb weakness
New floaters
Weight loss
Increased thirst
Increasing hand size

A

Increasing hand size – this is a bitemporal hemianopia, classic of a pituitary adenoma, which present with gradual and progressive visual and/or endocrinological symptoms. In this case, GH adenoma → acromegaly

50
Q

gradual vision loss causes

A

Diabetic retinopathy
Hypertensive retinopathy
Age Related Macula Degen
Cataracts
Open-angle glaucoma

51
Q

Sudden loss of vision

A
  • Optici neuritis
  • Central retinal artery occlusion
  • Central retinal vein occlusion
  • Retinal detachment
  • Posterior vitreous detachment
  • Vitreous hameorrhage
  • Transient
52
Q

Optic neuritis

A

– Related to MS

Findings
- RAPD
- dyschromatopsia (colour blindness)
- unilat reduction in visual acuity
- pain worse w/ movement

53
Q

Central retinal artery occlusion

A

Due to thromboembolisms or arteritis e.g. temproal arteritis

Findings
- unilat Loss of vision
- RAPD
- cherry-red spot on pale retina,

Emergency- treated like a stroke

54
Q

central retinal vein occlusion

A

more common than artery
causes
- glaucoma, polycythaemia, hypertension

Presentation
- unilat Loss of vision
- RAPD
- stormy sunset appearance
- retinal haemorrhage can be seen

55
Q

Retinal detachment

A

Features of vitreous detachment, which may precede retinal detachment, include flashes of light or floaters (see below)
* F Floaters (small dark spots on a bright background are generally harmless)
* F Flashes (migraine)
* F Field loss (dark cloud covers a field of vision)
* F Falling acuity (serious)

56
Q

vitreous detachment, which may precede

A

retinal detachment,
- first signs are flashes of lights or floaters

57
Q

Vitreous haemorrhage

A

– spectrum, DM or trauma, painless unilat LOV
- Flashes of light (photopsia)- in the peripheral field of vision
- Floaters, often on the temporal side of the central vision

58
Q

posterior vitreus detachment vs retinal detachment

A

A PVD occurs when the vitreous pulls away from the retina. When a PVD occurs, bleeding can possibly occur and as the vitreous gel pulls away, it might cause holes or rip tears in the retina. A retinal detachment occurs when the retina is separated from the back of the eye wall.

59
Q

Transient causes of vision loss

A

GCA, TIA, migraine, MS

60
Q

ischaemic cause of transient loss of vision

A

‘Amaurosis fugax’
- wide differential including large artery disease (atherothrombosis, embolus, dissection), small artery occlusive disease (anterior ischemic optic neuropathy, vasculitis e.g. temporal arteritis), venous disease and hypoperfusion
- ischaemic optic neuropathy is due to occlusion of the short posterior ciliary arteries, causing damage to the optic nerve

  • may represent a form oftransient ischaemic attack(TIA).

Presentation
- ‘curtaincoming down’
Management
- It should therefore be treated in a similar fashion, withaspirin 300mgbeing given

61
Q

A 45-year-old presents to the GP with a painful right eye. He was hammering a metal block with a chisel and not wearing eye protection, and his right eye suddenly became painful and his vision is blurry. On examination, there is a small conjunctival laceration with some subconjunctival haemorrhage, but you cannot see any foreign body.

Following an urgent referral to the ophthalmologist, what would be the most appropriate investigation?

CT scan
MRI
Ultrasound
Fluorescein-staining slit-lamp
Plain XR

A

CT scan – high likelihood of metallic intraocular foreign body, XR or CT is fine

NOT MRI IF POTENTIALLY METAL

62
Q

FOREIGN BODY & ABRASIONS symptoms

A
  • FB sensation
  • Watering
  • Redness
  • Photophobia
  • Vision rarely affected
63
Q

FOREIGN BODY & ABRASIONS investigations

A

Slit-lamp examination w/ fluorescein stain
If high-risk IO injury → **CT (not MRI if metallic body suspected) + to be seen by ophthalmologist

64
Q

managemet of foreign body

A

Surface FB → irrigation or removal
Corneal abrasions → ABx ointment
IntraOcular FB → surgical removal

All need follow-up in 24 hrs

65
Q

opthalmic abrasiaon management

A

Non contact wearer:
- An ophthalmic antibiotic ointment (eg, bacitracin/polymyxin B or ciprofloxacin 0.3% 4 times a day for 3 to 5 days) is used for most abrasions until the epithelial defect is healed.

  • Contact lens wearers with corneal abrasions require an antibiotic with optimal antipseudomonal coverage (eg, ciprofloxacin 0.3% ointment 4 times a day).

For symptomatic relief of larger abrasions (eg, area > 10 mm2), the pupil is also dilated once with a short-acting cycloplegic (eg, one drop cyclopentolate 1% or homatropine 5%).

Prognosis The corneal epithelium regenerates rapidly; even large abrasions heal within 1 to 3 days. A contact lens should not be worn until the injury is healed.

66
Q

Advice for people with superficial corneal injuries

A
  • Wearing sunglasses or staying out of areas of bright light may help with symptoms of light sensitivity.
  • Advise the person on suitable eye protection to prevent injury in the future and provide patient information.
  • The eye should not be touched or rubbed and contact lenses should be avoided while the eye recovers.
67
Q

A 29-year-old man attends A&E with a 1-week history of pain in his right ear. He has not seen his GP prior to this as he thought it would resolve with simple painkillers. On examination, you find his right ear is bulging outwards and the skin behind it is erythematous and swollen. He is afebrile.

What is the most appropriate management for the likely condition?

PO steroids
IV antibiotics
PO antibiotics
PO antibiotics and PO steroids
IV antibiotics and PO steroids

A

Mastoiditis
IV antibiotics – given for 1-2d, then stepped down to PO

68
Q

You are the F1 in GP doing a telephone consultation with a 31-year-old woman who is too dizzy to see you at the surgery. She woke up this morning feeling very dizzy, describing the sensation as the room spinning. Apart from ‘a bit of a cold’ a few days ago, she is otherwise fit and well.

Given the likely diagnosis, how should you manage the patient?

Prochlorperazine in the acute phase

Betahistine in the acute phase – little evidence

Prochlorperazine for the duration of the illness – interferes with central compensatory mechanisms

Betahistine for the duration of the illness – little evidence

Vestibular rehab exercises – for chronic symptoms

A

Prochlorperazine in the acute phase – give for a few days only; if vomiting, give IM